PPPs can be instrumental in improving quality of diagnostic and treatment services to cancer patients, opines Dr Ashok Mehta, Medical Director, Brahma Kumaris’ Global Hospital & Research Centre
Cancer is an important public health problem due to a sharp rise in the incidence of cancer in India. At any point of time, there are nearly 25 lakh patients in the country, with over 10 lakh new cases every year being added. Six lakhs die each year due to cancer. It is projected that 16 lakh new patients of cancer will be seen in 2020. Currently, there are only a limited number of formal screening programmes and regular examinations to identify individuals with the disease before visible symptoms. Early diagnosis is also hindered by lack of local specialised education of medical personnel and by the non availability of state-of-art medical equipment. 80-90 per cent of lung and prostate cancer and more than half of breast cancer patients report to the hospitals in advanced stage1. Treatment of advanced cancer results in poor cure rates and tremendous suffering to the patient and the family, besides financial calamity.
The sharp rise in the incidence of cancer can be attributed to urbanisation, industrialisation, changes in life style, population growth and an increased longevity. Due to the increasing volumes of cancer patients the number of deaths attributed to this disease will grow exponentially over the next decade.
The supply of cancer diagnostic and treatment facilities has not been able to keep pace with the demand largely on account of high initial investment required; low paying power of the general population, shortage of cancer specialists and skilled manpower, and limited awareness.
It is estimated that currently there are about 25 regional cancer centres, 210 radiation therapy installations, 160 government hospitals and 350 private hospitals providing specialised oncology treatment in our country. Major cancer centres, mainly located in metro cities, are overcrowded and have long waiting lists. Only a very small percentage amongst the other hospitals provide comprehensive cancer treatment using a combination of surgical, medical and radiation oncology facilities under one roof.
Despite some laudable accomplishments in the health sector, the picture is generally bleak in oncology though India has some state-of-the-art, globally comparable tertiary care facilities. Economic Survey (2013) reported that India spends around 4.1 per cent of GDP (government spends one per cent approximately) on health making India the worst performer among the Brazil, Russia, India, China, South Africa (BRICS) group.
The problem of cancer treatment gets compounded with rising costs, uneven quality, increasing demand, etc. This calls for an urgent re-thinking on the part of the Government and private healthcare providers if they want to seriously address the impending calamity that would occur in the absence of some concerted, meaningful and effective measures.
Public Private Partnership (PPP) initiatives in healthcare is the much talked about `mantra’ since over a decade. Unable to meet the growing demands for healthcare, the Government is actively looking at the PPP model, due to public sector insufficiencies to provide efficient, effective good healthcare for cancer, compounded by lack of resources and management issues.
PPPs can serve as an instrument to improve quality of diagnostic and treatment services to cancer patients and enhance public benefits in the form of an increase in capacity.
Improved access to diagnostics and radiation therapy capabilities are needed. We have less than 0.08 PET-CT per million population. 620 more linear accelerators (Linac) are needed by 2020 to reach the global average of 5.4 Linacs/mn population. Limited facilities of radiation therapy machines coupled with limited availability of specialists is restricting access to cancer care for majority of the patients.
Government of Bihar through Bihar Medical Services & Infrastructure Corporation Ltd (BMSICL) has one of the largest plans for providing cancer diagnostic and treatment services with private participation and has taken initiative to set up a ‘cancer cluster’ in Bihar. Cancer treatment centres is being planned through the ‘build and operate’ concept. The model envisages government involvement in providing space, building and other infrastructural facilities whereas the private partner would be responsible for providing equipment and manpower as well as running and maintaining the facilities. Supervision and monitoring would be done by government through authority/ agency/ committee.
Cancer needs to be diagnosed and treated across all strata of society and both in the rural as well as urban settings. The model could assume a ‘hub-and-spoke’ format. Cancer-screening centres could be set up at strategic locations. Patients requiring advanced diagnostics and treatment could be directed to the hub which would be a tertiary care comprehensive cancer centre. The hub would offer all forms of cancer care, surgery, radiation therapy, chemotherapy, rehabilitation, etc.
Expansion of oncology care in Maharashtra is being planned as PPP projects at various community health centres (CHCs) and district hospitals. The comprehensive cancer centres could be established in major cities of the state again as PPP projects. This entire programme could be unfolded in a phased manner. This would ensure testing the model in phase one and replicating it in subsequent, yet rapid phases.
The PPP model of healthcare delivery needs to be fundamentally designed in such a way that the functions are carried out by professionally managed, proficient organisations.
The challenge is to convince and partner with non-public sector (NGOs, trusts, private providers) to develop cancer care facilities through innovative public-private partnerships that adopt equitable, quality service delivery, ethical practice and community partnership.
Private partners can assist in realising the government’s development goals and in devising comprehensive cancer care projects. They can also help in identifying and garnering appropriate and sufficient investments.
Healthcare delivery being a state matter, the government needs to create a conducive PPP environment for attracting private participation by way of initiatives such as support in infrastructure set up like land acquisition or providing space, offer inability gap funding, budgetary provisions for capital and operating expenses of PPP formulate specific guidelines and capacity building within government for managing PPP projects, etc.
There would be a certain component of indigent (free) and subsidised patient care that the government would refer to these hospitals through a ‘gate-keeper mechanism’. Such a method would help filter out the truly needy and economically challenged patients that could get free/ subsidised treatments. Government formulated health insurance schemes for this category of patients would further help in allowing the needy patients affordable care as well as cover some of their treatment costs.
At the national level, in 2009, the Health Minister’s Cancer Patient Fund (HMCPF) was created within the Rashtriya Arogya Nidhi scheme (RAN). It established a revolving fund in the regional cancer centres (RCC) to speed up financial assistance as treatment subsidies for poor patients. A sum of up to Rs one lakh was proposed as assistance to cancer patients in the BPL category.
As the private partner/ NGO would infuse substantial funds into the venture, it is but imperative that it be allowed to treat ‘full- fee paying patients’ thus cross-subsidising the weaker sections. Private partner would look for a reasonable return on its large investments for supporting the government in providing quality cancer care. There could be a well-defined profit-sharing arrangement between the government and the private player. The government could re-employ their share of the profit into similar hub-and-spoke models across the state.
PPPs will help increase the facilities for skilled human resources training of medical, para-medical and nursing staff to enhance good cancer care delivery standards. Community participation would instill a sense of social responsibility and empowerment for the members of the society who would act as informed and involved partners.
It is absolutely essential, nay mandatory that good and prompt healthcare reaches the common man in all spheres and geographies in India. It is obvious that resources are available but the will to spend it correctly and in a timely and honest manner is imperative. Time is apt to promote PPP for improving cancer care as the answer to get to the bottom of the problem and the pyramid. Yet this effort should be done with a great degree of honesty and conviction and a readiness to deliver to the masses what otherwise appears as only an unfulfilled agenda.
Cancer is the top priority area in view of increasing incidence and large number of patients who would need to be diagnosed early and treated properly to protect from extreme suffering and eventual painful death. New treatments being introduced in advanced countries are so expensive that they are beyond reach of an average citizen even in those countries. Expenditure on cancer is expected to grow by over 20 per cent over the decade. PPP should play a vital role to increase the facilities for cancer treatment manifolds and reduce the cost of treatment.
It is a challenge to increase access to quality cancer care. PPP appears to be a viable alternative. Working with NGOs having good track record will provide community participation.
1. Tumours more than five cm in size or spread beyond the breast to other parts of the body